Central Board of Accreditation for Healthcare Institutions المجلس المركزي لاعتماد المنشآت الصحية

1. Central Board of Accreditation for Healthcare Institutionsالمجلس المركزي لاعتماد المنشآت الصحية CBAHI SURVEY PROCESS

2. Introduction form CBAHI chairman

4. Session 1 Introduction

5. Introduction

6. Accreditation An organization is assessed by an external body to determine its performance compliance with agreed standardsand the impact of its services on the patients. المستشفيات تقيم بواسطة مؤسسة وهيئة خارجية من أجل تحديد مستوى الأداء بالمقارنة مع معايير تلك الهيئة وبما يتطابق مع احتياجات المرضى

7. International Accreditation Body AccreditationOrganizations National Accreditation Body CBAHI: Central Board for Accreditation of Health care Institutions

8. The CBAHI Accreditation Standards The CBAHI Accreditation Standards were developed by a consensus process of health care experts representing • MOH • national guards hospitals • KFSH&RC • University hospitals • Private hospitals • Security Forces hospital • Saudi Council for Health Specialties • MRQP team • the standard have been approved by DR. HAMMED ALMANE (Minster of health) – National Standards Preparation committee on 21-24 May 2006.

9. CBAHI Accreditation Purpose مساعدة المستشفيات في تثبيت أسس وقواعد العمل سلامة المريض تحسين مستوى الرعاية الصحية

10. Mission • Improvement of healthcare quality standards in the Kingdom by supporting healthcare institutions to implement and accredit the medical quality standards and patient safety by national origin working systems, universal implementation, and distinguished efficiency.

11. Vision • Prestigious Global Commission in Healthcare quality development field. Values • Commitment to excellence • Belief in team work • Application of quality standards • Holistic approach • Integrity

12. CBAHI Theme

13. Session 2 How CBAHI Supports Hospitals?

14. How CBAHI Supports Hospitals?

15. WWW.CBAHI.ORG/RM cbahi

16. Std. Statement Std. Intent Preparation Tool (PT) Teaching tools Sample

17. SELFASSESSMENT The process starts with the Hospitalcompleting the self assessment www.cbahi.org/hospital

18. Hospital Accreditation Guide • The hospital can download the HAG from this site www.cbahi.org/hospital

19. Hospital Accreditation Guide

20. Hospital Accreditation Guide

21. Hospital Reporting Site • Preparation Tools (PT) are statements that detail the specific performance expectations and/or structure or process that must be in place • هي جمل تفصل الأداء المتوقع لكل معيار ، ومن خلال استيفاءها يتم التكامل مع المعيار وبها يكون المستشفى جاهز لأي نوع من التقييم • PT are evaluated by the following scale: 0 = insufficient compliance 1 = minimal compliance 2 = partial compliance 3 = satisfactory compliance

22. Example of MS chapter

23. Example of pharmacy chapter

24. Example of IC chapter

25. Session 3 Survey Process

26. Survey Process

27. CBAHI Surveyor Team (1) or two (2) days) (3) or four (4) days All seven will go together first day during accreditation surveys and may be on different day during mocks.

28. CBAHI Survey Process • Hospital accreditation Result has to be approved by the Central Board before it is given to the hospital. • The surveyors are not permitted to provide hints to the hospital regarding the accreditation status .

29. Applicability of Chapters and Standards • In general, organization wide chapters are mandated chapters. • They are: Leadership, Medical Staff and provision of care, Nursing, Quality and Patient Safety, Patient and family rights, patient and family education, Infection control, pharmacy, laboratory, facility management and safety, management of information and medical records. Ambulatory services, Emergency Room, Anesthesia, Dietary Service, and Social Work functions are applicable to all hospitals.

30. Applicability of Chapters and Standards

31. Scoring Method The hospital must meet all the applicable standards elements at a satisfactory level to become accredited. Each standard element is scored on a four-point scale: Initial Survey • “3” = Fully Met when ≥ 75 % compliance with the standards elements. • “2” = Partially Met when ≥ 50 to < 75 % compliance with the standards elements. • “1” = Minimally Met when ≥ 25 to < 50 % compliance with the standards elements. • “0” = Not Met when < 25 % compliance with the standards elements.

32. Accreditation Decision Rules • General Principles • All CBAHI chapters have equal weight regardless of the standard contents. Additionally, all standards within a chapter weigh equally. • Each standard is assigned ONE point. The ONE point is divided equally among the elements when more than one required element exists.

33. Accreditation Decision Rules • The score of each standard represents the mean score of the included elements. • Each chapter score is calculated as the mean of standards scores. The overall hospital score is calculated as the mean of the scores of all chapters. All scores are presented as percentage.

34. Accreditation Decision Rules: • Accredited– The hospital is awarded accreditation if: • the overall compliance score equals to or more than 80 % • No more than 2 chapters score less than 50%

35. Accreditation Decision Rules: We were asked: • Why the passing mark is 80%? • And the answer is: • We do not have bold standards • More than 70% of our standards are essential structural standards.

36. Accreditation Decision Rules: • Accreditation Denied – The hospital will be denied accreditation if: • the overall score is less 70 % or • more than 2 chapters score less than 50 %

37. Accreditation Decision Rules: • 70 to 79% Hospitals scoring from 70 to 79% is required to be resurveyed within 90 days of the result for chapters that score less than 50% Validity of accreditation: every 3 years

38. Session 4 HOSPITAL SURVEY ACTIVITIES

39. Survey Activities Agenda

40. Hospital Survey Activities

41. Documents Review • The hospital is expected to prepare binders to facilitate the review of their documents in relation to compliance to the CBAHI National Hospital Standards. • The binders to be organized according to the list provided in this guide. • The list reflects the arrangements based on the surveyor conducting review (not based on the chapters). • It is very much encouraged that the surveyor counter-part is oriented to the document arrangement.

42. Document Review General Guidelines • The scope of this activity is to ensure hospital adherence to the CBAHI requirements, especially that most standards main requirements are the presence of policies and/or completion of certain records • The 1st document surveyors need to review and clarify as a team is the hospitals' policy management system (policy on policies), which is addressed in LD.28. The hospital should introduce their system in the opening conference.

43. Document Review General Guidelines • If a needed document is not available the surveyor will ask the hospital representative to present it preferably within the survey day. The hospital will be given chance to present any missing evidence within the survey period.

44. Document Review General Guidelines • (PH-IC-FMS-LAB): for specialty area, evidence of compliance must be presented within the specialty survey day (by the end of day 1) • Hospitals will be considered in compliance with the standards requirements if a track record of the past four (4) months of the survey date was presented, such as meeting minutes and data trends or 4 meeting minutes.

45. Medical Records Review General Guidelines • Hospitals are requested to have the list of the last month discharge patients ready by the Surveyors Planning Session on day 1. • Required medical record list will be requested after the Opening Conference based on the month discharged cases • Hospitals to clarify their documentation guidelines prior to the medical records review session to smooth the process

46. Personnel File Review General Guideline • The scope of the personnel file review is the completeness of documentation of the recruitment, orientation, evaluation, continuing education, privileges and competencies process and monitoring. • Hospitals are encouraged to present the needed documentation in one location to ensure comprehensiveness of personnel data and history during his/her employment in the organization.

47. Leadership Interview • Decision making process based on data, • Participation in quality improvement activities • Understanding of patient safety concept and goals, • Understanding of hospital mission, • Sentinel events and OVR reporting, Root Cause Analysis • Patient and family right

48. Staff Interview and Observations • Unit rounds for Staff Interview and Observations • posting and knowledge of hospital mission, • OVR reporting, • understanding of assigned jobs, • Understanding of infection control guidelines, • Understanding of safety and security codes,

49. Visits to Patient Care settings • During these visits the survey team may talk with managers, direct care providers, and patients. The team also observe: • Reviews open medical records • Environment of care • Infection control • Patient care • Staff communications • Patient rights issues

50. Hospital Survey Report Hospitals will be able to access their survey report through their "hospital portal". The report face-sheet will show the overall final score and the scores of each chapter.